Intro to Evidence Based

Medicine Resources
Nancy Clark
FSU College of Medicine

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 Objectives
Students will
Formulate a clinical question
Identify and utilize EBM online resources to
answer their questions
EBM Databases
Guidelines
Apply rules for levels of evidence to make
clinical decisions

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 Assessment
Triple Jump Exam, 2nd yr
1. Have a simulated patient or paper case
2. Go to your computer, the web or your Palm
for pertinent information
3. Present patient and information collected to
attending

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 The EBM Process

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 The EBM Process
The patient 1. Start with the patient -- a clinical problem or
question arises out of the care of the patient
The question 2. Construct a well built clinical question derived from
the case
The resource 3. Select the appropriate resource(s) and conduct a
search
The evaluation 4. Appraise that evidence for its validity (closeness to
the truth) and applicability (usefulness in clinical
practice)
The patient 5. Return to the patient -- integrate that evidence with
clinical expertise, patient preferences and apply it to
practice
Self-evaluation 6. Evaluate your performance with this patient
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 Types of Questions
Therapy/prevention Question

Prognosis Question

Diagnosis Question

Harm Question

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 Elements of a Good Question
Who? Write the question
What? Type of question?
Alternately? Type of Study?
Outcome?

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 Summary
Type of Question Suggested best type of Study

Therapy RCT>cohort > case control > case series

Diagnosis Prospective, blind comparison to a gold standard
Etiology/Harm RCT > cohort > case control > case series
Prognosis Cohort study > case control > case series
Prevention RCT>cohort study > case control > case series
Clinical Exam Prospective, blind comparison to gold standard
Cost Economic analysis

http://www.hsl.unc.edu/lm/ebm/Supplements/QuestionSupplement.htm

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 Evidence Pyramid

Meta-Analysis

Systematic Review

Randomized Controlled Trial

Cohort studies

Case Control studies

Case Series/Case Reports

Animal research

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 Levels of Evidence
Level 1: Randomized Clinical Trials
Level 2: Head to Head Trial or
Systematic Review of Cohort Studies
Level 3: Case-Control Studies
Level 4: Case-series
Level 5: Expert Opinion

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 Levels of Evidence
Level 1: Highest:
Level 2:
Level 3:
Level 4:
Level 5: Lowestbut still evidence

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 Purpose-specific resources
CDC Travel
Drug information resources
Patient Education handouts
Diagnostic Testing ARUP
Medical Search engines
Textbooks
Journals

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 EBM Databases
Systematic Literature Searches
Cochrane Library (OVID)
Clinical Evidence
Systematic Literature Surveillance
ACP Journal Club (OVID)
DARE
DynaMed
Medical InfoRetriever
EMB Search Engine
TRIP Database

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 Today
National Guidelines Clearinghouse
(AHRQ)
Cochrane
ACP Journal Club
Dynamed
First Consult
InfoRetriever

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 Guidelines
What is a guideline?
Guidelines may be
Explicit evidence-based
Evidence-based
Research-based (highly referenced)
Opinion-based
expert consensus

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 Guidelines
National Guideline Clearinghouse
Primary Care Clinical Practice Guidelines
Agency/Association sites
AAFP
APA
AAP

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 Cochrane Library
The current resource with the highest
methodological rigor
For each clinical question, all of the English
literature meticulously searched for randomized
trials
Large systematic reviews with valid methods +
collaborative effort
Conclusions are based on all the evidence from
valid randomized trials

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 Cochrane Library
Included in OVID subscription
Limitations
limited to English
only addresses questions amenable to randomized trials
most of medicine has not been studied enough to allow
for conclusions
$235/year or abstracts only

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 ACP Journal Club
About 100 journals systematically surveyed
Highest-validity articles abstracted
Structured abstracts to guide critical appraisal
Clinical commentary
Included in our OVID subscription

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 ACP Journal Club
Limitations
individual article summaries may not account for the
big picture
may have to read multiple items
No control over what is covered
$78/year ?

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 DynaMed
Designed as entry point to information
Textbooks and Medline not efficient
Intuitive clinical organization
Brief summarized information presented
Links and references if more details needed
ICD-9 codes and links to patient
information handouts

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 DynaMed format
Description Prognosis
Etiology Treatment
Increased Risks Prevention
Associated Conditions Screening
Complications References
History (cc, HPI, etc.) Patient Information
Physical
Diagnostic (including
Rule out, Tests to order)

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 DynaMed Sources
18 primary journals e.g. BMJ, JAMA,
Lancet, NEJM, Pediatrics
12 secondary literature sources e.g.
Alternative Therapies, ACP Journal Club,
Cochrane Library, InfoPOEMs
4 drug info sources e.g. The Medical
Letter, FDA MedWatch

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 DynaMed
Limitations
variable quality
areas with a lot of research can get hard to
navigate
$200/year or effort

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 First Consult/PDxMD
By MDConsult
Differential Diagnosis
Disease Information
Patient Education Handouts

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 PDxMD

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 Medical InfoRetriever
104 journals surveyed for Evidence-Based
Practice Newsletter
Over 1300 article synopses/ POEMS
Cochrane abstracts
Selected evidence-based guidelines
Basic drug info
Clinical calculators/prediction rules

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 Symbols

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 InfoRetriever
Comes in web, desktop and PDA versions
Limitations
individual article summaries may not account for the
big picture
may have to read multiple items
$249/year
Optimized for use with Internet Explorer 5.x or
Netscape 6.x

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 Hands-On Experience

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